Healthcare Provider Details

I. General information

NPI: 1598445231
Provider Name (Legal Business Name): JON WESLEY HICKMAN SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W J ST
TEHACHAPI CA
93561-1411
US

IV. Provider business mailing address

410 W J ST
TEHACHAPI CA
93561-1411
US

V. Phone/Fax

Practice location:
  • Phone: 661-750-0438
  • Fax:
Mailing address:
  • Phone: 661-750-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15484
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: